CMHC/MFT Intern Contract Rev. 08/26/12 1

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1 CMHC/MFT Intern Contract Rev. 08/26/12 1 Western Kentucky University Department of Counseling and Student Affairs Clinical Mental Health Counseling; Marriage and Family Therapy Internship Site and Supervision Contract Date: Student Name: Address: City: State: Zip: Home Telephone: Cell Phone: WKU Site and Site Supervisor Information Name of Site: Name of Site Supervisor (with degree and credentials: Address of Site: Phone: Site Supervisor Choose Program: Clinical Mental Health Counseling Marriage & Family Therapy What semester are you applying for? Summer Fall Spring What Internship Course Section do you prefer to be enrolled in? Please include a second preference if more than two sections of Internship are available. Department of Counseling and Student Affairs Roles and Responsibilities 1. Provide an orientation for site supervisors at least once a year 2. Provide assistance, consultation, and professional development opportunities to site supervisor as needed Faculty Supervisor Qualifications, Roles and Responsibilities

2 CMHC/MFT Intern Contract Rev. 08/26/12 2 The Faculty Supervisor agrees to the following: 1. Has doctoral degree and/or appropriate counseling preparation, preferably from a CACREP-accredited counselor education program. 2. Has relevant experience and appropriate credentials/licensure and/or demonstrated competence in counseling. 3. Has relevant supervision training and experience. 4. Will work in biweekly consultation with site supervisor in accordance with the supervision contract 5. Will provide an average of 1 1/2 hours per week of group supervision provided on a regular schedule throughout the internship. 6. Will observe a student s interactions with clients through audio/video recordings and/or live supervision. 7. Will provide regular feedback to students they supervise in individual /triadic supervision about their development as counselors. 8. During internship, will consult with site supervisors regarding student progression and midterm and final evaluations. Faculty supervisors discuss evaluations with students and site supervisors and obtain site supervisors and students signatures on these evaluations. Site Supervisor Qualifications, Roles and Responsibilities The Site Supervisor agrees to the following: 1. Has a minimum of a master s degree in counseling or a related profession with equivalent qualifications, including appropriate certifications and/or licenses. 2. Has a minimum of two years of pertinent professional experience in the program area in which the student is enrolled. 3. Has relevant training in counseling supervision. 4. Is knowledgeable of the program s expectations, requirements, and evaluation procedures for students. 5. Will attend a Site Supervisor s orientation offered by the Department of Counseling and Student Affairs 6. Will take advantage of assistance, consultation, and professional development opportunities provided by counseling program faculty as needed 7. Will provide weekly interaction with each practicum student that averages one hour per week of individual and/or triadic supervision throughout the internship.

3 CMHC/MFT Intern Contract Rev. 08/26/ Will regularly observe a student s interactions with clients through audio/video recordings and/or live supervision 9. Will make sure that there is a fully licensed individual on-site and available whenever students are seeing clients. In addition, site supervisors must accompany students all on home visits or any direct service outside of the agency 10. Will provide regular feedback to students they supervise about their development as counselors. 11. During internship, will consult with faculty supervisors for midterm and final evaluations. Site supervisors will discuss midterm and final evaluation with faculty supervisors and students; and will sign the evaluations along with faculty supervisors and students. 12. Will provide students an opportunity to obtain 120 hours of direct service with clients. a. Direct service with clients may include conducting initial intakes, individual counseling, group counseling, and family or couples counseling. Direct service may only include hours spent in the above mentioned capacities to actual clients at the agreed upon site. No more than 50% of the direct service can include group counseling hours. b. Marriage and Family Therapy students must complete at least 30% of their total clock hours of direct service in a relational modality (i.e., 36 hours of couples, families, or family sub-systems such as grandfather and grandchild, siblings). c. Students will have opportunities to make video recordings for use in supervision with both faculty supervisor and site supervisor. Video recording of clients should be done on a consistent and regular basis throughout the internship experience. The Internship Student s Roles and Responsibilities The Internship Student understands the following: 1. Two supervised internships must include 300 clock hours each, begun after the successful completion of the practicum. The internship is intended to reflect the comprehensive work experience of a professional counselor appropriate to the designated program area. 2. Each internship must include 120 clock hours of direct service, including experience leading groups. a. Direct service with clients may include conducting initial intakes, individual counseling, group counseling, and family or couples counseling. Direct service may only include hours spent in the above mentioned capacities to actual clients at the agreed upon site. That is, work with volunteer clients or clients not affiliated with the site are not considered direct service and are

4 CMHC/MFT Intern Contract Rev. 08/26/12 4 not a part of the supervised practicum experience. No more than 49% of the direct service can include group counseling hours. b. Marriage and Family Therapy students must complete at least 30% of their total clock hours of direct service in a relational modality (i.e., 36 hours of couples, families, or family sub-systems such as grandfather and grandchild, siblings). c. Program-appropriate video recordings must be developed for use in supervision with both faculty supervisor and site supervisor. Video taping of clients should be done on a consistent and regular basis throughout the internship experience. Students are responsible for providing videos on formats that Faculty and Site Supervisors have access to (DVD, thumb drive). 3. Attend at least one hour of weekly individual and/or triadic supervision throughout the internship with site supervisor while sharing videos of work with clients. 4. Attend all group supervision meetings with faculty supervisor. 5. In order to progress to the second Internship, all course requirements must be met with a minimum of a B in the first Internship course. Video Media and Security Agreement 1. Videos of counseling sessions in CNS classes will meet HIPAA standards for security. This standard states that a video must, at all times, be in a double lock security situation. For example, videos stored in a locked file cabinet (lock 1) in a room that has a locked door (lock 2) meet the double lock requirement. 2. When transporting videos and from practicum and classroom sites, a video placed in a locked car does not meet the requirement. Students and faculty are required to have videos locked in the trunk of their cars to meet this requirement. 3. I have read and understand my responsibilities in referencing videotaping, storage and destruction. Additionally, I understand my responsibilities include keeping my practicum/internship supervisor(s) informed of any irregularities occurring with the videoing process during my practicum/internship. Student Evaluation Criteria and Procedures Students are continuously evaluated during their practicum and internship experiences. This occurs during weekly supervision meetings when students receive feedback from supervisors and peers regarding their performance and formally at midterm and at the conclusion of the semester. These evaluations are done by faculty supervisors in the practicum and in internships by site supervisors. Midterm and final evaluations

5 CMHC/MFT Intern Contract Rev. 08/26/12 5 involve faculty and site supervisors consultation. Completed evaluations are discussed with students by faculty and site supervisors, signed by students and supervisors, and placed in students practicum and internship files. Dates of Contract This Internship Site and Supervision Contract is made by and between (Internship Site) and Western Kentucky University Department of Counseling and Student Affairs. The agreement will be effective for a period from to for Internship Student,. All parties signing to this Contract understand and accept the policies and respective responsibilities as noted. Internship Student Date Site Supervisor Date Clinical Coordinator Date Include the following documents with this contract: a. Site Supervisor s vita (only if it has not been previously submitted to the Department) b. Proof of Professional Membership (i.e., ACA, AMHCA, AAMFT, KCA, KAMFT) c. Copy of Malpractice Insurance Instructions for completing this form: d. Save this form to your computer. Save with the file name: Your Last Name + Your First Initial + InternContract + MonthYear. For example, SauerheberJInternContract0911 e. Fill out all of the form fields on the computer. Resave it. f. Print it; sign and date it, gather signature and date from Site Supervisor. g. Scan the file, resave it. h. Submit the file by the due date.